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ED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (one form per UST) TYPE OF ACTION (Check one item only. For a UST closure or removal, complete only this section and Sections I, A III, IV, and IX below) 430. ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ® 5. CHANGE OF INFORMATION ❑ 6. TEMPORARY UST CLOSURE ❑ 7. UST PERMANENT CLOSURE ON SITE ❑ 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430,,. 1 DATE EXISTING UST DISCOVERED: 430b. I. FACILITY INFORMATION 1. FACILITY ID# (Agency Use Only) Q Q 7 8 1 1 BUSINESS NAME (Same as Facility Name or DBA - Doing Business, As) 3. Kaiser Permanente Medical Center BUSINESS SITE ADDRESS 103. Cly 104 1777 W. Yosemite Ave. Manteca H. TANK DESCRIPTION TANK ID # 432. TANK MANUFACTURER 433. TANK CONFIGURATION: THIS TANK IS 434. 1 Owens Coming P ❑ 1. A STAND-ALONE TANK Complete one n ge for each ® 2. ONE IN A COMPARTMENTED UNIT compartment DATE UST SYSTEM INSTALLED 435. TANK CAPACITY IN GALLONS 436. NUMBER OF COMPARTMENTS IN THE UNIT 437. 6/1988 8,000 1 III. TANK USE AND CONTENTS TANK USE ❑ la. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ 1c. AVIATION FUELING 439. ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used Oil) ® 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a. _❑_6._OTHER CONTENTS PETROLEUM: v- ❑ 1a. REGULAR UNLEADED ❑ Ic. MIDGRADE UNLEADED ❑ ib. PREMIUM UNLEADED ® 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440a;,___. .� NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUMS i :'' IV. TANK CONSTRUCTION 443. -__ TYPE OF TANK_ ❑ 1. SINGLE WALL ® 2. IXDUBLE WALL ❑ 95. UNKNOWN_ - .. PRIMARY CONTAINMENT [31. STEEL N 3. FIBERGLASS ❑ 6. INTERNAL BLADDER ' ® 7. STEEL + INTERNAL_ LINING_ ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 444a _ SECONDARY CONTAINMENT ❑ 1. STEEL ® 3. FIBERGLASS �❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445. ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 445a. OVERFILL PREVENTION ❑ 1. AUDIBLE & VISUAL ALARMS [12. BALL FLOAT ® 3. FILL TUBE SHUT-OFF VALVE 452. ❑ 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION E UIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ 1. SINGLE WALL ® 2. DOUBLE WALL ❑ 99. OTHER 460. SYSTEM TYPE ® 1. PRESSURE - ❑ 2. GRAVITY - - ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION [23 CCR §2636(a)(3)1 458. PRIMARY CONTAINMENT ® 1. STEEL ❑ 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGID PLASTIC aha. [390. NON_ E ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 454a _ _b _ SECONDARY CONTAINMENT E]1. STEEL ® 4. FIBERGLASS El8. FLEXIBLE ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 95. UNKNOWN_ ❑ 99. OTHER (S ift'): -._` -__ _ PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d. VI. VENT, VAPOR RECOVERY ) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ® 1. STEEL [14. FIBERGLASS ❑ 10. RIGID PLASTIC 1190. NONE 1199.OTHER (Specify): 4�j. 464f. VENT SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS - ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99.OTIiIIt (Specify): 464n. 464g. VR PRIMARY CONTAINMENT - 0 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 46481. VR SECONDARY CONTAINMENT [11. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC [190. NONE ❑ 99. OTHER (Specify): 46�4hl. EING TRANSITION SUMP TYPE ❑ 1. SINGLE WALL [12. DOUBLE WALL ® 90. NONE VNTPIP _- RISER PRIMARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ® 90. NONE ❑ 99. OTHER (Specify): RISER SECONDARY CONTAINMENT ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify): 464ki._._ FILL COMPONENTS INSTALLED ® 1. SPILL BUCKET ® 3. STRIKER PLATFJBOTTOM PROTECTOR ❑ 4. CONTAINMENT SUMP a§ia c. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE ❑ 1. SINGLE WALL ❑ 2. DOUBLE WALL ® 3. NO DISPENSERS ❑ 90. NONE _ 469a. CONSTRUCTION MATERIAL ❑ 1. STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 99.OTHER (Specify) 446699c. VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ® 6. ISOLATION 448. IX. APPLICANT SIGNATURE CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full compliance with legal reAuirements. azo. APPLICANT SIGNATURE DATE 8/3/2011 APPLICANT NAME (print) Samuel A .Corbin 471. APPLICANT TITLE Chief Engineer 472 UPCF UST -B Rev. (12/2007) -1/2 www.unidocs.org